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C.U. Thresia was trained in anthropology, social medicine, and community health; her research interests span politics and history of public health, and women’s health. She is currently pursuing research on health inequities in the history of public health development in Kerala.

Social inequalities and exclusions can devastate people’s lives, especially when they are far from the centers of power and control. This wreckage can be seen in many different parts of their lives, but particularly in their health. The health of any given country’s population is primarily determined by politics, and public policies play a critical role. All over the world, countries with a history of egalitarian ideologies, and corresponding policies aimed at reducing social inequalities, have healthier populations.1 The Indian state of Kerala, which has a long-running radical political tradition and a history of social-reform movements in the early twentieth century, is acclaimed for its achievements in health and social-sector development, including low levels of mortality and fertility, and high levels of life expectancy and literacy—all despite its low-performing economy. Kerala has become a veritable mecca for other low-income nations in social development and health advancement. Some argue that Kerala is important as a model for third world countries, where centuries of colonialism and decades of Western-sponsored development initiatives have created high levels of inequality and misery for the poor.2

Scholars such as Amartya Sen have attributed many of the advancements in Kerala’s health and social development in the second half of the twentieth century to the democratization process, agrarian reforms, and public action. Others have emphasized the role of health-care services and education, particularly women’s education, in achieving better health.3 These claims were often made without much epidemiological basis and conceptual clarity.4 The state’s strong communist movement and its politics in welfare policies contributed to gains in social-sectoral development in Kerala.5 They have given an impetus to anti-capitalist political traditions the world over. But they have also helped international development agencies (including the World Bank, United Nations, and the Rockefeller Foundation—all financially and ideologically supported by the advanced capitalist nations) to promote a “model” for poorer countries which argues that economic growth is not necessarily a precondition for social development.

However, in the global public-health discourses the “good health at low cost” experience in the post-Second World War and post-colonial world—mainly in China, Cuba, Kerala, and Sri Lanka (all areas with communist revolutionary traditions), as well as Costa Rica—foreshadowed the comprehensive social-development-oriented notion of “primary health care” which was put forward in the 1978 Alma-Ata Declaration. This perspective in public health appropriate for developing nations focuses on health-system development with an emphasis on fulfilling basic needs, including health care, and changing both the distribution of resources as well as the underlying socioeconomic conditions.

Unfortunately, a conceptual shift to “selective primary health care”—a fragmented, technocentric, and individual-disease-focused vertical model, which is also more conducive to liberal ideology—cropped up within a year, and by the early 1980s was endorsed by UNICEF (United Nations Children’s Fund). Not surprisingly, such a shift was under the pretext of insufficient improvement in the population-control measures in the developing countries.6 However, even after several years of “vertical interventions,” preventable diseases remain a major challenge for developing countries, while the initiatives to suppress principles of primary health care in favor of an unscientific, market-driven agenda have resulted in the virtual disappearance of public-health practice in countries like India.7

In today’s globalized and liberalized world there is a huge concentration of economic, political, social, and cultural resources and powers among the dominant classes, groups, and genders, in both the global North and South, while the health and well-being of the other classes are endangered. This is reflected in the widening health inequities and health-system failures in both the developed nations and developing nations,8 including the “good health at low cost” regions. Notably, even in Kerala, data indicates that such deprivation is not just limited to the poor, but in recent decades has expanded far beyond this.

Kerala has a lengthy history of social-reform movements, and anti-caste, anti-feudal, and anti-imperialist struggles. Post-independence Kerala had a few solid Communist ministries until the mid–1970s (elected at different intervals) which promised agrarian reforms, and thereafter often had alternating left and non-left governments with relatively better welfare inputs.9 Yet, the left could not contain the enduring inequities of caste, class, gender, and ethnic exclusions in health and social development.10 Furthermore, in addition to the widening health and income inequities, there are newer forms of marginalization appearing, including increasing informal employment, immigrant labor with higher levels of exploitation, and ecological devastation, as part of the changing socioeconomic, political, and cultural context of neoliberalism.

It is in this context of locating health and development in a wider sociopolitical, cultural, and ecological perspective (as an interconnected and interacting whole), that the inequities and exclusions in Kerala’s health and social development, and its linkages with an interdisciplinary approach, will be explored. First, the health achievements and inequities in Kerala health will be looked at, followed by the historical trajectories of “egalitarian” development, contemporary politics, and public policies which impede health equity and social justice.

Health Achievements

Kerala’s health achievements date back to the early decades of the last century. Mortality rates started declining steadily in the 1920s, and by 1940 Kerala had the lowest death rate among the major states in India. By the late 1970s, Kerala’s health and educational gains improved substantially and the state began to achieve indices comparable to the developed world. In 1977–1978 the estimated crude death rate in Kerala was a seven, lower than developed countries’ average estimate of nine. During the same period, infant mortality fell to three times lower, and life expectancy increased considerably higher, than the national Indian figures.11 In 2009, the infant mortality rate in Kerala was only twelve, comparable to the upper-middle-income countries such as China (fourteen) and Costa Rica (ten and a half). Life expectancy (seventy-four years) was comparable to economically advanced countries such as the United States (seventy-six), Canada (seventy-nine), or to communist Cuba (seventy-eight). Today, Kerala ranks highest in the human development index in India, a country with the highest under-five-years-old child-mortality rate (26 percent) in the world; this is several times higher than sub-Saharan African and other South Asian countries such as Democratic Republic of Congo (7 percent), Pakistan (5 percent), or China (4 percent).12 However, Kerala’s health achievements do not preclude an analysis of the health inequities and the challenges it faces.

Health Inequities and Challenges

Despite its history, the progress of health improvements in Kerala, especially after the 1990s, was not impressive. The infant mortality rate increased 9 percent between 2003 and 2012; childhood anemia increased from 44 to 56 percent and underweight conditions among the children younger than three increased from 27 to 29 percent between 1998 and 2006, according to the National Family Health Surveys.13 During the same period, child immunization coverage declined from 80 to 75 percent, whereas levels of anemia among ever married women ages fifteen to forty-nine increased from 22.7 to 32.4. Further, the state faced several public-health challenges, including the burden of new infectious diseases, rising chronic morbidity, declines in mental health, lack of access to quality health care, medical poverty, and widening health inequities across class, caste, gender, and ethnic groups. (Medical poverty is the rise in out-of-pocket expenses for both public and private medical care which is driving many into poverty, and increasing the poverty of those who are already poor.) This has been particularly true during the last two decades of neoliberal policies, which were characterized by increased marketization and weakened public-sector provisions.14 Not surprisingly, deprivation related to medical poverty, morbidity burdens, and lack of access to health care are found to be more prominent among the poor, lower castes, and indigenous tribal peoples.15

Undermining the fact that health is a goal of state action and it is determined by wider political and social factors, the state seeks solace in promoting the growth of private-sector health care. The neoliberal period witnessed the mushrooming of high-technology diagnostic centers, multi-specialty hospitals, and teaching institutions (medical colleges), and a variety of public-private partnership schemes including insurance (Rashtriya Swastya Bhima Yojana) and the Karunya Benevolent Scheme. As part of these schemes, the government has given substantial sums to private institutions in the previous year. On the other side, there are few efforts to improve the quality of public-sector health-care services due to the dwindling resource base. Although the National Rural Health Mission increased funding for this, its results were disappointing due to its fragmented and technocentric approach. Unfortunately, the private institutions and schemes have little transparency and accountability while the government, irrespective of who is in power, has failed to regulate, standardize, and control the private sector. Often there are widespread unethical practices, including medically unwanted surgeries, unnecessary and expensive laboratory tests, and inappropriate drug prescriptions. However, these malpractices are not just limited to the large-scale private sector.16 Notably, small- and medium-sized private health-care institutions, with relatively smaller capital investments and that cater to the lower-middle class in remote areas, are on a decline. Indeed, all these factors indicate that the state painfully lacks public-health competence, and the bungling public-health administration and health-ministerial leadership add to such woes. Even the decentralization of Kerala’s health sector, according to a government report, did not yield the expected results; this was due to a number of reasons, including the burden of resource mobilization which the local self-government institutions were left with, and a poor interface between these institutions and medical professionals.

However, inequities in Kerala’s health and social-sector development are not limited to just the periods of neoliberalism; although a proper study is yet to be done, these inequities reflect historical divisions in geographic terrain, region, caste, class, gender, and ethnicity. During the early twentieth century, the infant mortality rate in the Malabar region, under British rule, was nearly double that of Thiruvathamcoor-Kochi, the South-Central region under princely rule (210 to 120). Similar inequities existed in different geographical terrains of the state; the high-land was more disadvantaged in health indices compared to the middle- and low-lands, although the differentials across these geographical regions and terrains have narrowed down significantly.17 Similarly, even though Kerala is renowned for its low levels of caste and ethnic discrimination, the legacy of inequities has been reflected in higher levels of birth and death, infant mortality, and morbidity rates, and comparative lack of access to health care among the lower castes and tribes.18 In terms of out-of-pocket medical care and resultant medical poverty, tribes were more vulnerable and devastatingly disadvantaged followed by the Scheduled castes.19 Although at least some of the lower castes enjoy the benefits of Kerala’s social achievements, ethnic discrimination leaves tribes fully deserted, with a staggering toll of ill-health, misery, landlessness, and poverty.

Gender inequities pose another major challenge, despite the mortality and fertility gains of women’s health in Kerala. Beyond the conventional indicators there are a number of dimensions in women’s health, including increasing violence against women, a high rate of suicides (and suicide attempts), declining mental health, higher morbidity, and reduced access to health care, which have all been masked due to gender bias in health research and policy.20 In the rural areas of the state, suicide is the chief cause of death among women aged fifteen to twenty-four.21

In addition to these structural issues, the changing global and local sociopolitical, cultural, and environmental context has created newer health issues and challenges in the state. There is a dearth of information on health issues related to increasing emigration and immigration, while those related to the cuts in public expenditure—including nutrition and employment—have yet to be analyzed. Nevertheless, public-health erosion was more apparent in the recent decades. This is likely to be a result of ecological degradation from lopsided development projects and a radical shift in land-use patterns and agricultural practices, including the use of lethal pesticides such as endosulphan, as well as a lack of proper management of solid and liquid waste. In short, all these inequities and challenges are closely interlinked with the state’s historical and sociopolitical development process, since health outcomes are socially and politically rooted.22

Issues in “Egalitarian” Social Development

Given that health is largely determined by politics and public policies, the state’s “egalitarian” social- and health-development pathways have benefited from Kerala’s unique history of anti-caste and anti-feudal struggles, social-reform movements, radical political mobilizations, and matrilineal traditions. Further, the missionary educational endeavors, indigenous systems of medicine, and a favorable environment with abundant natural resources, were all factors in the health and social developmental gains. Nevertheless, the state’s social-development history has also been riddled with a variety of structural inequities and disparities of class, caste, gender, and ethnicity as well as issues of poverty and unemployment. Indeed, these unaddressed inequities, which have a decisive role in determining the health of the local population, date back to the period before independence. Historically, Kerala has had overwhelming levels of poverty and unemployment, although the recent National Sample Service Organization statistics indicate a sharp decline. Since the 1950s Kerala has had the highest unemployment in the country, and today the proportion of unemployment of the educated in the state has assumed alarming proportions. Even in 1998, the organized workforce in Kerala was only equal to the workforce who had emigrated abroad. Likewise, in 1970–1971, the proportion for rural and urban areas of the population below the poverty line (rural: 69.0 percent; urban: 62.4 percent) was considerably higher than the corresponding figures for the rest of India (rural: 57.3 percent; urban: 45.9 percent).23 Although there has been a reversal since 1983–1984, Kerala still retains several pockets of poverty, especially in the traditional sectors of the economy such as agriculture, cashew processing, coir, handloom weaving, and fishing. However, pointing to the flaws in the assessment of poverty, Prabhat Patnaik, the ex-Vice Chairman of the Kerala State Planning Board, argues that during 1993–1994, in the direct assessment of rural poverty based on caloric requirement (2,400/day), 84 percent of the people would be poor, as opposed to the 25 percent reported by the Planning Commission. While even at a lower level of 1,800 calories, the prevalence of poverty would be 40 percent in 1993–1994 and 38 percent in 1999–2000.24 Notably, community-based studies indicate that during the late 1990s and early 2000s, 80 percent of the agricultural and 70 percent of the cashew-processing households respectively did not have two full meals a day for all its members all around the year.25

Similarly, the historical legacy of caste and ethnic discrimination is apparent in several spheres of Kerala’s development process, even though today the caste system no longer explicitly epitomizes political power and economic hierarchies. A lot of water has flowed under the bridge of history since the anti-caste, anti-feudal, nationalist, and leftist movements of pre-independence Kerala. Then the lower castes enjoyed hardly any rights, owned far less land, and were virtually absent in public-sector employment and higher education. Even in 1968, only 4 percent of Scheduled castes were salaried, compared to 52 percent of Brahmins.26 Furthermore, the globally acclaimed land reforms of the early 1970s were of little benefit to the vast majority of the landless agricultural laborers, drawn largely from the lower castes. In 1992, the average landholding of Scheduled castes in Kerala (0.07 hectares) was less than the Indian average for the same group (0.49 hectares). Nor did the better wages in the state improve their consumption status, since monthly per capita consumption expenditure for Scheduled castes in 1983–1984 was only about three-fourths of the non-Scheduled castes.27 Even worse, tribals were gradually alienated from their land: their ancestors, gods, goddesses, and women were taken away (the proportion of unwed tribal mothers was enormously high), and much of the tribal population became laborers of the settlers in highly exploitative conditions burdened with horrendously high levels of poverty, illiteracy, and lack of access to health care.

The anguish of caste and ethnic deprivation was more evident in the recent uprising for land by tribals and Scheduled castes, despite the brutal retaliation by both left and non-left governments. Excepting a very small proportion of the lower castes who can reap the benefits of public policies, the majority of the Scheduled castes, and nearly all of the Scheduled tribes, seem damned to remain the “wretched” of Kerala. Despite the “democratization” of caste hierarchy which occurred in Kerala through the historic anti-caste, anti-feudal, and leftist movements, even in the 1990s there was not much leveling or abolition of caste identities in the state.28

The history of social development in Kerala favored women to a certain extent, and their general health and educational gains were well acclaimed. However, despite Kerala ranking number one in India’s gender development index, evidence shows that beyond the conventional indicators, it has been like any other state in the country.29 The persistence of higher levels of gender inequities is illustrated by women’s limited representation in the political power structure, subjugation in economic spheres, far lower levels of land ownership and technological education, predominance in less-capital-intensive and low-technology work under exploitative conditions, limited decision-making roles in the household and public sphere, and in increasing violence against them.30 Given Kerala’s sturdy patriarchal history, it is hardly surprising that the women’s (and girls’, too) desire for freedom and dignified life is met with undemocratic relations: increasing rape, sexual harassment, and cruelty by husbands and relatives.31

While structural inequities play a major role in overturning the history of social and health improvements in the state, developments in contemporary Kerala arising out of “growth mediated development” policies since the late 1980s have created newer forms of deprivation and adversity. The increasing migration and resulting remittances of the late 1980s helped revive economic growth, and between the 1980s and ‘90s a million people left Kerala.32 However, during this time the increase of organized workers in the state was only by 230,000 and factory workers only by 71,000. Furthermore, the radical shift in agriculture from rice paddy farming to more perennial and profitable crops resulted in a decline in the agricultural working class. But this did not result in the growth of industrialization and an industrial working class; rather, it reinforced cleavages including widening income inequalities and growing informal-sector employment. Given the higher wages in the countryside, the transformations in the employment market and the low preference for manual and relatively less technically skilled jobs within the state led the way for a heavy influx of migrant labor, which may lead to further social and public-health problems.

The far-reaching impact of the shift in agriculture is also likely to lead to food-security problems since there was an over three-fold decline in the area of rice cultivation, and in production from 1 million to 500,000 tons, between 1960 to 2010. This agricultural shift also paved the way for indiscriminate land-use patterns: massive conversion of paddy fields and wetlands for commercial purposes, including booming construction and real estate businesses. The thriving “real estate mafia” in Kerala makes land a precious commodity by reclaiming wetlands, destroying hills, clearing forests, and converting rivers and ponds to cesspools as byproducts of sand mining for construction.

In short, along with the structural inequities, these transformations—including migration, shifts in agriculture, increasing informal-sector jobs, increases in pay for the salaried class, and legitimate and illegitimate accumulation through avenues such as real estate—have all accelerated ecosystem pathologies, economic cleavages, newer class relations, and inequities in health and social-sector development in the state. The ostentatious consumer culture of the middle class is booming, while the poor and the marginalized become more vulnerable, with widening income and health inequalities. These are the outcomes of contemporary politics and policies.

Contemporary Politics

Kerala’s sociopolitical history of radical movements helped improve the state’s health and social development. Today’s global and national environment, which is more conducive for unfettered market growth, is characterized by increasing class divisions and inequality, and the contemporary politicians in Kerala assume that private capital is the only path to growth and development. Reluctant to learn from their own history, and defining development as “economic growth,” the government—whether left-wing or not—desperately seeks national and international capital, emphasizing tourism and information technology as the main sources to develop the economy and generate employment. However, the disappointing outcome—only a trifle sum of investment resulted—of the much-hyped global investor meet, a massive call for private capital by the non-left-wing government in 2003 seems to have continued in “Emerging Kerala,” another investor meet by the same ruling front. This time, perhaps, the disarray is related to issues of land and ecological devastation, since many of the tourism projects are in, or on the fringes of, ecosensitive forest areas. Sadly enough, Kerala’s Communist government (most recently 2007–2011), which vowed to fight capitalism and globalization, tried their best to proclaim that they were not against foreign capital, ecohazardous projects, or even proposals for special economic zones which destroy the socioeconomic and cultural habitat of the state. Perhaps, these meetings turned out to be good opportunities for getting land and resources from the government for a pittance, compared to the open market. Except for a few small social movements, the larger political fronts were by-and-large unpardonably silent about each other’s lopsided development initiatives throughout these recent past decades.

Despite Kerala’s reputation for achievements in health and in reducing social inequalities, the recent period has seen a disquieting trend in these arenas. Indeed, throughout the development process, the Scheduled castes, Scheduled tribes, and women gained little or nothing. Evidence shows that caste/ethnic inequities were not extinguished nor were the disadvantaged enabled to compete with the upper caste/class populations on equal terms. Mounting gender inequities and violence against women in the state, shameful to any democratic polity, indicate the social pathologies of capitalist and patriarchal dominations, and their associated insecurities and commercialization of human relations. With the increasing consumerist culture of Kerala’s middle and upper classes, they have also shown relatively better health indices, while Scheduled castes, Scheduled tribes, and women have fallen yet further behind.

However, evidence indicates that political traditions which are more committed to economic and social redistribution and full-employment policies are more successful in improving the health of populations.33 Kerala’s non-left government has been strangled in rampant corruption and yielding to community politics (where organizations bargain for community-based benefits). Meanwhile, the left is riddled with internal strife, political vengeance, and a transformation in their political-economic arenas from cooperatives to corporations.34 More than ever, there is a pressing need for the left to play a major role in Kerala. Unfortunately, there is a glaring mismatch between the left’s ideals and its actual policies and programs on critical issues such as land, agriculture, health, and development—as well as issues of caste, gender, and ethnic inequities. Such a political milieu favors the growth of communal forces and community politics, rather than creating a social environment conducive for delineating equitable public policies and strategies to take on the health and development challenges of the state. A successful communist party needs ideological unity to make its political capability and strength operate in contact with the masses.35 This necessitates a critical reanalysis of the newer class relations, exclusions, and inequities in Kerala’s contemporary health and social development process with an interdisciplinary perspective. A unitary approach to the complexities of health inequities and social exclusions, to the biological/medical, social, political, economic, cultural, and environmental aspects of a deteriorating situation, is demanded by the times.36

↩Imrana Qadeer. “Political and Economic Determinants of Health,” in Harold John Cook, Sanjoy Bhattacharya, and Anne Hardy, eds., History of the Social Determinants of Health (Hyderabad: Orient Blackswan, 2009); Debabar Banerji, “Reconstructing the Critically Damaged Health Service System of the Country,” International Journal of Health Services 42, no. 3 (2012): 439–64.

↩The use of the word left is synonymous with communists since the left in Kerala is largely constituted and led by the Communist Party of India Marxist–CPI (M). The Communist Party of India–CPI and Revolutionary Socialist Party–RSP are also partners.